State Hawaii Tdi 45 Form – Fill Out and Use This PDF

1.

My name is: (First, Middle, Last) Type or print

2.

Social Security Number

3.

Birth Date

4.

Mailing address: (Street, City or Town, State, Zip Code)

5.

Telephone Number

6.

7.

o Male

o Single

o Female

o Married

9.

The first day I was unable to perform the duties of my job:

10.

Was this disability caused by your job?

o Yes

o No

o Unknown

(month)

(day)

(year)

11.

o I have not recovered from my disability.

12.

o I have not returned to work.

o I have recovered from my disability.

o I have returned to work.

Date recovered:

Date returned:

13.

My present employer is: (or last employer, if unemployed)

14.

Prior to my disability, I worked for this employer:

(Name and address - include street, city, state, zip code)

From:

To:

15.

I worked:

hours per week

and

I earned $

per week

16.

Occupation:

17.

I am a union member.

o Yes

Name of union:

o No

18.

Other Hawaii employers I worked for during the past 52 weeks:

Period of Employment

Weekly

From

To

Hours

Wages

Employer name and address

Month

Day

Year

Month

Day

Year

a.

b.

c.

d.

19.

Does your employer have a printed TDI notice posted and maintained conspicuously in your employment area?

o Yes

o No

Did your employer inform you of your entitlement to TDI benefits?

o Yes

o No

Did your employer provide you this claim form when you first requested it for this disability?

o Yes

o No

OTHER BENEFITS

20. In addition to TDI benefits, I am receiving or claiming benefits from the following: (Check those that apply)

o Federal Disability Insurance Benefits

o Unemployment Insurance Benefits

o Workers’ Compensation Benefits

o Damages for Personal Injury

o Employer’s Sick Leave Plan

o Other (Health and Welfare Fund; Union Plan, etc.)

21.

During the 52 weeks (year) before my disability began, I have received TDI benefits for other periods of disability

o Yes

o No

If yes, from whom

From

To

22. Mail the doctor’s statement to the insurance carrier unless otherwise indicated here:

Claimant’s signature

E-mail address

Date

Representative’s signature, if claimant is unable to sign

Print representative’s name

Relationship

1.

Claimant’s Name

2.

Claimant’s Occupation

3. Employer Department of Labor No.

4. Group and Account Number

5. Firm or Trade Name

6. Business Address

7.

In reporting wage information below, use gross wages, which include wages and all other

8.

Worked:

o Full-time

o Part-time

remuneration such as commissions, bonuses, tips and the cash value of meals, lodging, etc.

Date hired:

Answer either A, B, or C.

(month)

(day)

(year)

Date last worked prior to disability:

A. If claimant was paid on a salary basis, enter claimant’s weekly or monthly salary earned

in the last week or month prior to the date claimant’s disability began:

(month)

(day)

(year)

If returned to work, give date:

Week $ ______________

Month $ ______________

(month)

(day)

(year)

B. If paid on an hourly basis, give rate per hour $ _____________. Enter the weekly

9. Check days normally worked:

earnings for the past 8 weeks prior to the date disability began, including the last

o Sun o

Mon

o Tues o Wed o

Thurs o Fri o Sat

date worked. (Include reported tips)

If on rotation, give the number of days worked per week

Weekending

10.

Enter the following for the last 52 weeks prior to the date the

Week

No. Days

Gross

No.

Month

Day

Year

Worked

Amount

employee’s disability began:

1

Calendar

No. of

No. of Hours

Total Wages

Quarter Ending

Weeks Worked

Worked Per Wk.

Earned

2

3

4

5

6

7

8

11.

Do you think this disability was caused by the claimant’s job?

o Yes

o No

o Unknown

Total

XXXX

XXXX

XXXX

Was an Employer’s Report of Industrial Injury WC-1 filed?

C. If claimant received any or all earnings on a commission or piecework basis, enter these

o Yes

o No

earnings for the last 52 weeks prior to the date claimant’s disability began:

This covers the period:

If yes, advise name and address of Worker’s Compensation Carrier

From: ______________ through ______________

(month/day/year)

(month/day/year)

Earnings: $ ______________

13.

Mail the doctor’s statement to:

12.

Has or will this employee receive all or any portion of the

period of disability covered by this claim?

Wages?

o Yes

o No

Salary?

o Yes

o No

Sick leave pay?

o Yes

o No

Vacation pay?

o Yes

o No

Separation pay?

o Yes

o No

If yes, show period:

Amount

From:

(mo/day/yr)

$_________

Through:

(mo/day/yr)

1.

Claimant’s Name

2. Age

3.

Sex

4.

Physical requirements of claimant’s occupation as related by claimant:

5.

Diagnosis:

6.

If pregnancy, advise expected date of birth __________________________________. If disability is pregnancy with complications, advise complications above.

7.

Was claimant’s disability caused by claimant’s employment?

o Yes

o No

If yes, was Physician’s Report WC-2 filed? o Yes o No

If yes, filed with _____________________________________________________________

8.

Was claimant hospitalized?

o Yes

o No

If yes, from ______________________ to ______________________

Surgery indicated?

o Yes

o No

Type _____________________________________________________________

9.

Complete the following:

Month

Day

Year

Date of your first treatment of this disability

First date claimant unable to perform the duties of employment (see #4 above)

Date of your most recent treatment of this disability

Date claimant will be able to perform usual work (estimate) (DO NOT use “undetermined” or “unknown”) (See #4 above)

10.

Are you referring claimant to another physician?

o Yes

o No

If yes, give name ____________________________________________________

OR

Was claimant referred to you?

o Yes

o No

If yes, give name ____________________________________________________